Encouraging patients with depressive symptoms to seek care: a mixed methods approach to message development

Mental health service preferences of patients and providers: a scoping review of conjoint analysis and discrete choice experiments from global public health literature over the last 20 years (1999-2019)

BACKGROUND

In designing, adapting, and integrating mental health interventions, it is pertinent to understand patients' needs and their own perceptions and values in receiving care. Conjoint analysis (CA) and discrete choice experiments (DCEs) are survey-based preference-elicitation approaches that, when applied to healthcare settings, offer opportunities to quantify and rank the healthcare-related choices of patients, providers, and other stakeholders. However, a knowledge gap exists in characterizing the extent to which DCEs/CA have been used in designing mental health services for patients and providers.

METHODS

We performed a scoping review from the past 20 years (2009-2019) to identify and describe applications of conjoint analysis and discrete choice experiments. We searched the following electronic databases: Pubmed, CINAHL, PsychInfo, Embase, Cochrane, and Web of Science to identify stakehold,er preferences for mental health services using Mesh terms. Studies were categorized according to pertaining to patients, providers and parents or caregivers.

RESULTS

Among the 30 studies we reviewed, most were published after 2010 (24/30, 80%), the majority were conducted in the United States (11/30, 37%) or Canada (10/30, 33%), and all were conducted in high-income settings. Studies more frequently elicited preferences from patients or potential patients (21/30, 70%) as opposed to providers. About half of the studies used CA while the others utilized DCEs. Nearly half of the studies sought preferences for mental health services in general (14/30, 47%) while a quarter specifically evaluated preferences for unipolar depression services (8/30, 27%). Most of the studies sought stakeholder preferences for attributes of mental health care and treatment services (17/30, 57%).

CONCLUSIONS

Overall, preference elicitation approaches have been increasingly applied to mental health services globally in the past 20 years. To date, these methods have been exclusively applied to populations within the field of mental health in high-income countries. Prioritizing patients' needs and preferences is a vital component of patient-centered care - one of the six domains of health care quality. Identifying patient preferences for mental health services may improve quality of care and, ultimately, increase acceptability and uptake of services among patients. Rigorous preference-elicitation approaches should be considered, especially in settings where mental health resources are scarce, to illuminate resource allocation toward preferred service characteristics especially within low-income settings.

Can Mental Health Anti-stigma Messages Have Untoward Effects on Some People with Depression?: An Exploratory Study

Scholars have warned that mental health anti-stigma campaigns targeting the general public can possibly be detrimental to some who are stigmatized. Scholars also have noted that people with depression respond to some public service announcements (PSAs) differently than those without. Accordingly, the current study explored whether anti-stigma PSAs targeting the general public could cause problematic outcomes for people with depression. Participants with (n = 55) and without (n = 133) heightened depressive symptomatology viewed two mental health anti-stigma PSAs. Participants provided thoughts about the PSAs through a single, open-ended question. To allow for an assessment of convergence, participants rated overall favorability toward each PSA through a close-ended item. Results indicated that most qualitative responses were favorable; however, 23.6% of respondents with heightened depressive symptomatology, compared to 1.5% without, provided responses coded as indicating that at least one PSA caused unintended negative affect, χ²(1) = 25.96, [Formula: see text] p < .001. Evidence of untoward effects primarily came from the Friend PSA and the qualitative responses indicate how this occurred. Moreover, complementing the qualitative coding, the Friend PSA was rated less favorably by participants with heightened depressive symptomatology (M = 5.00, SD = 1.67), than those without (M = 5.64, SD = 1.44), F(1, 186) = 6.99, p = .009, η_p² = .036. There were no significant differences in quantitative favorability ratings regarding the Labeling PSA. Indicating that further investigation is warranted, results suggest it is possible for an anti-stigma PSA targeting the general public to cause unintended negative affect among some people with depression.

Help-seeking and people with aphasia who have mood problems after stroke: perspectives of speech-language pathologists

BACKGROUND

Access to treatments for mood disorders may pose a challenge to individuals with compromised communication ability. Speech-language pathologists (SLPs) have previously reported that their clients with aphasia decline formal psychological support; however, their role in their clients' help-seeking has not been explored.

AIMS

To investigate SLPs' perspectives on how they currently support help-seeking for mood problems in people with aphasia and factors they perceive to be impacting service uptake.

METHODS & PROCEDURES

A qualitative interview study was conducted. SLPs in Australia working with people with aphasia in a clinical role were recruited. Transcripts of the interviews were subject to qualitative analysis to identify relevant themes.

OUTCOMES & RESULTS

Eighteen interviews were conducted. One overarching theme and three sub-themes were identified as central to SLPs' experience. The overarching theme was of a 'double whammy' impact on help-seeking: people with aphasia were subject to universal barriers associated with seeking help as well as additional barriers imposed by compromised communication. Three themes contributed to the overarching theme: (1) SLPs' understanding of barriers and facilitators to patients with aphasia seeking help; (2) the role of the SLP as a skilled helper for mood management; and (3) mood and communication as competing rehabilitation priorities.

CONCLUSIONS & IMPLICATIONS

SLPs report both universal barriers to help-seeking and those specific to their clients with aphasia and attempts to overcome these; however, there appears to be a dearth of accessible mental health services for people with aphasia known to SLPs, including psychological/counselling professionals who are skilled in communicating with people with aphasia. Health professionals working within and across post-stroke and mental health services should recognize that people with post-stroke aphasia are susceptible to a decline in mental health, are amenable to formal (and tailored) psychological support, and can be supported to seek help.

Long-Term Particulate Matter Exposure and Onset of Depression in Middle-Aged Men and Women

BACKGROUND

Long-term exposure to particulate matter (PM) air pollution is associated with all-cause mortality and adverse cognitive outcomes, but the association with developing depression remains inconsistent.

OBJECTIVE

Our goal was to evaluate the prospective association between PM air pollution and developing depression assessed using the Center for Epidemiological Studies Depression (CES-D) scale.

METHODS

Subjects were drawn from a prospective cohort study of 123,045 men and women free of depressive symptoms at baseline who attended regular screening exams in Seoul and Suwon, South Korea, from 2011 to 2015. Exposure to PM with an aerodynamic diameter of [Formula: see text] ([Formula: see text] and [Formula: see text], respectively) was estimated using a land-use regression model based on each subject's residential postal code. Incident depression was defined as a CES-D score [Formula: see text] during follow-up. As a sensitivity analyses, we defined incident depression using self-reports of doctor's diagnoses or use of antidepressant medications during follow-up.

RESULTS

The mean baseline 12-month concentrations of [Formula: see text] and [Formula: see text] were 50.6 (4.5) and [Formula: see text], respectively. The hazard ratios (HRs) and 95% confidence intervals (CIs) for developing depression associated with a [Formula: see text] increase in 12- and 60-month [Formula: see text] exposure were 1.11 (95% CI: 1.06, 1.16) and 1.06 (95% CI: 1.01, 1.11), respectively. The corresponding HRs for 12-month [Formula: see text] exposure was 0.96 (95% CI: 0.64, 1.43). Similar results were obtained when incident depression was identified using self-reports of doctor's diagnoses or the use of antidepressant medications.

CONCLUSION

In this large cohort study, we found a positive association between long-term exposure to outdoor [Formula: see text] air pollution and the developing depression. We did not find an association for outdoor [Formula: see text] air pollution; however, we had a much shorter follow-up for subjects' exposure to [Formula: see text]. https://doi.org/10.1289/EHP4094.

Responses to persuasive messages encouraging professional help seeking for depression: comparison between individuals with and without psychological distress

BACKGROUND

The persuasive effect of health messages can depend on message features, audience characteristics, and target behaviors. The objective of this study was to compare the responses to persuasive messages encouraging professional help seeking for depression between individuals with and without psychological distress.

METHODS

A cross-sectional web-based survey was conducted on Japanese adults aged 35-45 years, who randomly received one of three persuasive messages that aimed to promote help-seeking intentions for depression. The primary message statements were as follows: (1) depression can happen to anyone, (2) depression needs treatment, and (3) depression improves with treatment. Participants rated the messages in terms of comprehensibility, persuasiveness, emotional response, and intended future use. Help-seeking intention for depression was measured using vignette methodology before and after exposure to the messages. Eligible participants who had not received medical treatment for their mental disorders were classified as either distressed (K6 score ≥ 5, N = 824) or non-distressed (K6 score < 5, N = 1133) and analyzed.

RESULTS

No significant differences in comprehensibility or persuasiveness scores were observed between the messages, but the distressed group had significantly lower scores than the non-distressed group. Negative emotional responses such as surprise, anger, fear, sadness, guilt, and anxiety were significantly stronger when reading message 2, while a positive emotional response such as happiness was significantly stronger when reading message 3. These emotional responses were more prominent in the distressed than in the non-distressed group. After reading messages 1, 2, and 3, the proportions of participants in the distressed group who reported having a positive help-seeking intention increased by 35.1%, 32.1%, and 27.7%, respectively, and by 6.4%, 17.3%, and 15.2%, respectively in the non-distressed group. Multiple logistic regression analysis among participants having no help-seeking intention before exposure to the messages showed that message 2 had a significantly greater effect of increasing help-seeking intentions in the non-distressed group.

CONCLUSION

The exposure to persuasive messages may promote help-seeking intentions for depression. It seems likely that loss framing will work better than neutral and gain framing. Meanwhile, the responses to persuasive messages may differ to some extent between distressed and non-distressed individuals, as individuals with psychological distress are likely to be more susceptible to persuasive messages than those without.

TRIAL REGISTRATION

Not applicable; this is not a report of intervention trial.

Can patients be trained to expect shared decision making in clinical consultations? Feasibility study of a public library program to raise patient awareness

Introduction

Shared decision making (SDM) is a process whereby decisions are made together by patients and/or families and clinicians. Nevertheless, few patients are aware of its proven benefits. This study investigated the feasibility, acceptability and impact of an intervention to raise public awareness of SDM in public libraries.

Materials and methods

A 1.5 hour interactive workshop to be presented in public libraries was co-designed with Quebec City public library network officials, a science communication specialist and physicians. A clinical topic of maximum reach was chosen: antibiotic overuse in treatment of acute respiratory tract infections. The workshop content was designed and a format, whereby a physician presents the information and the science communication specialist invites questions and participation, was devised. The event was advertised to the general public. An evaluation form was used to collect data on participants’ sociodemographics, feasibility and acceptability components and assess a potential impact of the intervention. Facilitators held a post-workshop focus group to qualitatively assess feasibility, acceptability and impact.

Results

All 10 planned workshops were held. Out of 106 eligible public participants, 89 were included in the analysis. Most participants were women (77.6%), retired (46.1%) and over 45 (59.5%). Over 90% of participants considered the workshop content to be relevant, accessible, and clear. They reported substantial average knowledge gain about antibiotics (2.4, 95% Confidence Interval (CI): 2.0–2.8; P < .001) and about SDM (4.0, 95% CI: 3.4–4.5; P < .001). Self-reported knowledge gain about SDM was significantly higher than about antibiotics (4.0 versus 2.4; P < .001). Knowledge gain did not vary by sociodemographic characteristics. The focus group confirmed feasibility and suggested improvements.

Conclusions

A public library intervention is feasible and effective way to increase public awareness of SDM and could be a new approach to implementing SDM by preparing potential patients to ask for it in the consulting room.

Comparing responses to differently framed and formatted persuasive messages to encourage help-seeking for depression in Japanese adults: a cross-sectional study with 2-month follow-up

OBJECTIVE

To examine audience's responses to differently framed and formatted persuasive messages in the context of developing depression help-seeking messages.

DESIGN

Cross-sectional followed by 2-month follow-up study.

SETTING AND PARTICIPANTS

A web-based survey was conducted in July 2017 among Japanese adults aged 35-45 years. There were 1957 eligible respondents without psychiatric history. Of these, 1805 people (92.2%) completed the 2-month follow-up questionnaire.

MAIN OUTCOME MEASURES

Six depression help-seeking messages were prepared with three frames (neutral, loss and gain framed)×2 formats (formatted and unformatted). Participants were asked to rate one of the messages in terms of comprehensibility, persuasiveness, emotional responses, design quality and intended future use. Help-seeking intention for depression was measured using vignette methodology before and after exposure to the messages. Subsequent 2-month help-seeking action for their own mental health (medical service use) was monitored by the follow-up survey.

RESULTS

The loss-framed messages more strongly induced negative emotions (surprise, fear, sadness and anxiety), while the gain-framed messages more strongly induced a positive emotion (happiness). The message formatting applied the Centres for Disease Control and Prevention Clear Communication Index, enhanced the emotional responses and increased the likelihood that the message will be read. The loss-framed formatted message alone had a significantly greater OR of having help-seeking intention for depression compared with the neutral-framed unformatted message as a reference group. All messages had little impact on maintaining help-seeking intention or increasing help-seeking action.

CONCLUSION

Message framing and formatting may influence emotional responses to the depression help-seeking message, willingness to read the message and intention to seek help for depression. It would be recommendable to apply loss framing and formatting to depression help-seeking messages, to say the least, but further studies are needed to find a way to sustain the effect of messaging for a long time.

A Comparison of Methods for Capturing Patient Preferences for Delivery of Mental Health Services to Low-Income Hispanics Engaged in Primary Care

BACKGROUND

Consideration of patient preferences regarding delivery of mental health services within primary care may greatly improve access and quality of care for the many who could benefit from those services.

OBJECTIVES

This project evaluated the feasibility and usefulness of adding a consumer-products design method to qualitative methods implemented within a community-based participatory research (CBPR) framework.

RESEARCH DESIGN

Discrete-choice conjoint experiment (DCE) added to systematic focus group data collection and analysis.

SUBJECTS

Focus group data were collected from 64 patients of a Federally-Qualified Health Center (FQHC) serving a predominantly low-income Hispanic population. A total of 604 patients in the waiting rooms of the FQHC responded to the DCE.

MEASURES

The DCE contained 15 choice tasks that each asked respondents to choose between three mental health services options described by the levels of two (of eight) attributes based on themes that emerged from focus group data.

RESULTS

The addition of the DCE was found to be feasible and useful in providing distinct information on relative patient preferences compared with the focus group analyses alone. According to market simulations, the package of mental health services guided by the results of the DCE was preferred by patients.

CONCLUSIONS

Unique patterns of patient preferences were uncovered by the DCE and these findings were useful in identifying pragmatic solutions to better address the mental health service needs of this population. However, for this resource-intensive method to be adopted more broadly, the scale of the primary care setting and/or scope of the issue addressed have to be relatively large.

Treatment disparities among African American men with depression: implications for clinical practice

A decade has passed since the National Institute of Mental Health initiated its landmark Real Men Real Depression public education campaign. Despite increased awareness, depressed African American men continue to underutilize mental health treatment and have the highest all-cause mortality rates of any racial/ethnic group in the United States. We review a complex array of socio-cultural factors, including racism and discrimination, cultural mistrust, misdiagnosis and clinician bias, and informal support networks that contribute to treatment disparities. We identify clinical and community entry points to engage African American men. We provide specific recommendations for frontline mental health workers to increase depression treatment utilization for African American men. Providers who present treatment options within a frame of holistic health promotion may enhance treatment adherence. We encourage the use of multidisciplinary, community-based participatory research approaches to test our hypotheses and engage African American men in clinical research.

Developing attributes for discrete choice experiments in health: a systematic literature review and case study of alcohol misuse interventions

Discrete choice experiments (DCEs) become increasingly popular to value outcomes for health economic studies and gradually gain acceptance as an input into policy decisions. Developing attributes is a key aspect for the design of DCEs, as their results may misguide decision-makers if they are based on an inappropriate set of attributes. However, the area lacks guidance, and current health-related DCE studies vary considerably in their methods of attribute development, with the consequent danger of providing an unreliable input for policy decisions. The aim of this article is to inform the progress toward a more systematic approach to attribute development for DCE studies in health. A systematic review of the published health-related DCE literature was conducted to lay the foundations for a generic framework which was tested in a case study of alcohol misuse interventions. Four stages of a general attribute development process emerged: (i) raw data collection; (ii) data reduction; (iii) removing inappropriate attributes; and (iv) wording. The case study compared and contrasted a qualitative and mixed-methods approach for the development of attributes for DCEs in the area of alcohol misuse interventions. This article provides a reference point for the design of future DCE experiments in health.

Discrete choice experiments in health economics: a review of the literature

BACKGROUND

Discrete choice experiments (DCEs) are increasingly used in health economics to address a wide range of health policy-related concerns.

OBJECTIVE

Broadly adopting the methodology of an earlier systematic review of health-related DCEs, which covered the period 2001-2008, we report whether earlier trends continued during 2009-2012.

METHODS

This paper systematically reviews health-related DCEs published between 2009 and 2012, using the same database as the earlier published review (PubMed) to obtain citations, and the same range of search terms.

RESULTS

A total of 179 health-related DCEs for 2009-2012 met the inclusion criteria for the review. We found a continuing trend towards conducting DCEs across a broader range of countries. However, the trend towards including fewer attributes was reversed, whilst the trend towards interview-based DCEs reversed because of increased computer administration. The trend towards using more flexible econometric models, including mixed logit and latent class, has also continued. Reporting of monetary values has fallen compared with earlier periods, but the proportion of studies estimating trade-offs between health outcomes and experience factors, or valuing outcomes in terms of utility scores, has increased, although use of odds ratios and probabilities has declined. The reassuring trend towards the use of more flexible and appropriate DCE designs and econometric methods has been reinforced by the increased use of qualitative methods to inform DCE processes and results. However, qualitative research methods are being used less often to inform attribute selection, which may make DCEs more susceptible to omitted variable bias if the decision framework is not known prior to the research project.

CONCLUSIONS

The use of DCEs in healthcare continues to grow dramatically, as does the scope of applications across an expanding range of countries. There is increasing evidence that more sophisticated approaches to DCE design and analytical techniques are improving the quality of final outputs. That said, recent evidence that the use of qualitative methods to inform attribute selection has declined is of concern.

Patient engagement programs for recognition and initial treatment of depression in primary care: a randomized trial

IMPORTANCE

Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment.

OBJECTIVE

To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California.

INTERVENTIONS

DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control).

MAIN OUTCOMES AND MEASURES

Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted.

RESULTS

Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95% CI, -1.2 to 0.8); IMCP vs control,  0.9 (95% CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90% CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control,  0.9 [90% CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control,  0.3 [90% CI, -5.1 to 5.7], P = .16 for noninferiority).

CONCLUSIONS AND RELEVANCE

A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01144104.

Targeted versus tailored multimedia patient engagement to enhance depression recognition and treatment in primary care: randomized controlled trial protocol for the AMEP2 study

BACKGROUND

Depression in primary care is common, yet this costly and disabling condition remains underdiagnosed and undertreated. Persisting gaps in the primary care of depression are due in part to patients' reluctance to bring depressive symptoms to the attention of their primary care clinician and, when depression is diagnosed, to accept initial treatment for the condition. Both targeted and tailored communication strategies offer promise for fomenting discussion and reducing barriers to appropriate initial treatment of depression.

METHODS/DESIGN

The Activating Messages to Enhance Primary Care Practice (AMEP2) Study is a stratified randomized controlled trial comparing two computerized multimedia patient interventions -- one targeted (to patient gender and income level) and one tailored (to level of depressive symptoms, visit agenda, treatment preferences, depression causal attributions, communication self-efficacy and stigma)-- and an attention control. AMEP2 consists of two linked sub-studies, one focusing on patients with significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] scores ≥ 5), the other on patients with few or no depressive symptoms (PHQ-9 < 5). The first sub-study examined effectiveness of the interventions; key outcomes included delivery of components of initial depression care (antidepressant prescription or mental health referral). The second sub-study tracked potential hazards (clinical distraction and overtreatment). A telephone interview screening procedure assessed patients for eligibility and oversampled patients with significant depressive symptoms. Sampled, consenting patients used computers to answer survey questions, be randomized, and view assigned interventions just before scheduled primary care office visits. Patient surveys were also collected immediately post-visit and 12 weeks later. Physicians completed brief reporting forms after each patient's index visit. Additional data were obtained from medical record abstraction and visit audio recordings. Of 6,191 patients assessed, 867 were randomized and included in analysis, with 559 in the first sub-study and 308 in the second.

DISCUSSION

Based on formative research, we developed two novel multimedia programs for encouraging patients to discuss depressive symptoms with their primary care clinicians. Our computer-based enrollment and randomization procedures ensured that randomization was fully concealed and data missingness minimized. Analyses will focus on the interventions' potential benefits among depressed persons, and the potential hazards among the non-depressed.

TRIAL REGISTRATION

ClinicialTrials.gov Identifier: NCT01144104.

An academic-marketing collaborative to promote depression care: a tale of two cultures

OBJECTIVES

Commercial advertising and patient education have separate theoretical underpinnings, approaches, and practitioners. This paper aims to describe a collaboration between academic researchers and a marketing firm working to produce demographically targeted public service anouncements (PSAs) designed to enhance depression care-seeking in primary care.

METHODS

An interdisciplinary group of academic researchers contracted with a marketing firm in Rochester, NY to produce PSAs that would help patients with depressive symptoms engage more effectively with their primary care physicians (PCPs). The researchers brought perspectives derived from clinical experience and the social sciences and conducted empirical research using focus groups, conjoint analysis, and a population-based survey. Results were shared with the marketing firm, which produced four PSA variants targeted to gender and socioeconomic position.

RESULTS

There was no simple, one-to-one relationship between research results and the form, content, or style of the PSAs. Instead, empirical findings served as a springboard for discussion and kept the creative process tethered to the experiences, attitudes, and opinions of actual patients. Reflecting research findings highlighting patients' struggles to recognize, label, and disclose depressive symptoms, the marketing firm generated communication objectives that emphasized: (a) educating the patient to consider and investigate the possibility of depression; (b) creating the belief that the PCP is interested in discussing depression and capable of offering helpful treatment; and (c) modelling different ways of communicating with physicians about depression. Before production, PSA prototypes were vetted with additional focus groups. The winning prototype, "Faces," involved a multi-ethnic montage of formerly depressed persons talking about how depression affected them and how they improved with treatment, punctuated by a physician who provided clinical information. A member of the academic team was present and consulted closely during production. Challenges included reconciling the marketing tradition of audience segmentation with the overall project goal of reaching as broad an audience as possible; integrating research findings across dimensions of words, images, music, and tone; and dealing with misunderstandings related to project scope and budget.

CONCLUSION

Mixed methods research can usefully inform PSAs that incorporate patient perspectives and are produced to professional standards. However, tensions between the academic and commercial worlds exist and must be addressed.

PRACTICE IMPLICATIONS

While rewarding, academic-marketing collaborations introduce tensions which must be addressed.

Feeling labeled, judged, lectured, and rejected by family and friends over depression: cautionary results for primary care clinicians from a multi-centered, qualitative study

Background

Family and friends may help patients seek out and engage in depression care. However, patients’ social networks can also undermine depression treatment and recovery. In an effort to improve depression care in primary care settings, we sought to identify, categorize, and alert primary care clinicians to depression-related messages that patients hear from friends and family that patients perceive as unhelpful or detrimental.

Methods

We conducted 15 focus groups in 3 cities. Participants (n = 116) with a personal history or knowledge of depression responded to open-ended questions about depression, including self-perceived barriers to care-seeking. Focus group conversations were audio-recorded and analyzed using iterative qualitative analysis.

Results

Four themes emerged related to negatively-received depression messages delivered by family and friends. Specifically, participants perceived these messages as making them feel labeled, judged, lectured to, and rejected by family and friends when discussing depression. Some participants also expressed their interpretation of their families’ motivations for delivering the messages and described how hearing these messages affected depression care.

Conclusions

The richness of our results reflects the complexity of communication within depression sufferers’ social networks around this stigmatized issue. To leverage patients’ social support networks effectively in depression care, primary care clinicians should be aware of both the potentially beneficial and detrimental aspects of social support. Specifically, clinicians should consider using open-ended queries into patients’ experiences with discussing depression with family and friends as an initial step in the process. An open-ended approach may avoid future emotional trauma or stigmatization and assist patients in overcoming self-imposed barriers to depression discussion, symptom disclosure, treatment adherence and follow-up care.

Patients' perspectives on depression case management in general practice - a qualitative study

OBJECTIVE

General practice-based case management is effective in improving symptoms, adherence, and the perceived process of care of patients living with major depression. The aim was to explore the patients' perceptions of practice-based depression case management, their satisfaction with it and how living with depression contextualizes case management.

METHODS

This qualitative study was nested in a large cluster-randomized controlled trial on the effectiveness of case management for patients living with major depression. Case management was provided over 12 months by practice-based health care assistants, who monitored symptoms. We undertook semi-structured interviews with 41 patients, then transcribed and analysed them using qualitative content analysis.

RESULTS

Patients described depression as the unfortunate situation, where loneliness and lack of energy lead to being unable to actively seek help. Case management was appreciated because of regular, proactive contact and support by health care assistants. It was crucial to patients that they could trust the health care assistant. Some patients complained that case management was undertaken too mechanically and lacked empathy.

CONCLUSION

Patients living with depression may perceive practice-based case management as beneficial if carried out in a trustworthy and empathetic manner.

PRACTICE IMPLICATIONS

General practices should ensure that depression case management is patient-centered and non-mechanical.

Role of the gender-linked norm of toughness in the decision to engage in treatment for depression

OBJECTIVE

Given their prevalence and persuasive power in our culture, gender norms--commonly described as socially reinforced, learned expectations of what it means to be a man or a woman--likely contribute to sex differences in service utilization for depression. This study investigated whether sex differences in toughness, a gender-linked norm characterized by a desire to hide pain and maintain independence, were associated with a preference to wait for depression to resolve on its own without active professional treatment ("wait-and-see" approach).

METHODS

Participants (N=1,051) in the California Behavioral Risk Factor Surveillance System (BRFSS) survey were contacted in a follow-on survey to assess toughness, the kind of treatment they would prefer were they to receive a diagnosis of depression, and current symptoms of depression. Participants who reported ever having been diagnosed as having a depressive disorder on the BRFSS were oversampled threefold. Analyses were conducted using linear and logistic regressions.

RESULTS

Men and women who scored higher on toughness had a greater preference for the wait-and-see approach (OR=1.14, p<.01). Women were less likely to prefer the wait-and-see approach (OR=.58, p<.04) and scored lower on toughness (B=-.70, p<.01). Men's greater levels of toughness partially mediated the sex difference in treatment preferences (OR=.91, p<.03).

CONCLUSIONS

Men's greater adherence to the toughness norm explained part of the sex difference observed in treatment-seeking preferences, but toughness undermined women's treatment seeking as well. Findings could be used to inform novel public health communications intended to attract both men and women to psychiatric services.

An illness perception model of primary care patients' help seeking for depression

Many people with depression recognize their symptoms as depression, but fail to seek treatment for a number of years. We aimed to explore the reasons for this. Thirty primary care patients who screened positive for depression participated in semistructured, face-to-face interviews. Transcripts were analyzed using grounded thematic analysis. Patients who sought depression treatment emphasized their understanding of depression, their belief that treatment would work, and the negative consequences that would ensue if they did not seek treatment. Patients who did not seek treatment emphasized that treatment would not be effective, thought that depression would not last very long, and believed that depression did not affect their everyday lives. Patients' illness perceptions of depression were represented by and organized using the framework of the Self-Regulation Model of Illness Behavior. This model might be useful for planning patient activation intervention studies to increase the uptake of depression treatment in primary care.

Suffering in silence: reasons for not disclosing depression in primary care

PURPOSE

Depression symptoms are underreported by patients. We thus assessed individuals' reasons for not disclosing depression to their primary care physician.

METHODS

We conducted a follow-up telephone survey of 1,054 adults who had participated in the California Behavioral Risk Factor Survey System. Respondents were asked about reasons for nondisclosure of depressive symptoms to their primary care physician, depression-related beliefs, and demographic characteristics. Descriptive and inferential statistical procedures were used to characterize perceived obstacles to disclosure.

RESULTS

Of the respondents, 43% reported 1 or more reasons for nondisclosure. The most frequent reason was the concern that the physician would recommend antidepressants (22.9%; 95% confidence interval, 18.8%-27.5%). Reported reasons for nondisclosure of depression varied based on whether the respondent had a history of depression. For example, respondents with no depression history were more likely to believe that depression falls outside the purview of primary care (P=.040) and more likely to fret about being referred to a psychiatrist (P=.036). Respondents with clinically significant depressive symptoms rated 10 of 11 barriers to disclosure as more personally applicable than did those without symptoms (all P values =.014). Number of reported disclosure barriers was predicted by demographic characteristics (being female, Hispanic, of low socioeconomic status), depression beliefs (depression is stigmatizing and should be under one's control), symptom severity, and absence of a family history of depression.

CONCLUSIONS

Many adults subscribe to beliefs likely to inhibit explicit requests for help from their primary care physician during a depressive episode. Interventions should be developed to encourage patients to disclose their depression symptoms and physicians to ask about depression.

Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial

OBJECTIVE

To test the effect of three questions (what are my options? what are the benefits and harms? and how likely are these?), on information provided by physicians about treatment options.

METHODS

We used a cross-over trial using two unannounced standardized patients (SPs) simulating a presentation of mild-moderate depression. One SP was assigned the intervention role (asking the questions), the other the control role. An intervention and control SP visited each physician, order allocated randomly. The study was conducted in family practices in Sydney, Australia, during 2008-09. Data were obtained from consultation audio-recordings. Information about treatment options and patient involvement were analyzed using the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool and the OPTION tool.

RESULTS

Thirty-six SP visits were completed (18 intervention, 18 control). Scores were higher in intervention consultations than controls: ACEPP scores 21.4 vs. 16.6, p<0.001, difference 4.7 (95% CI 2.3-7.0) and OPTION scores 36 vs. 25, p=0.001, difference 11.5 (95% CI 5.1-17.8), indicating greater information provision and behavior supporting patient involvement.

CONCLUSION

Asking these three questions improved information given by family physicians and increased physician facilitation of patient involvement. Practice implications. These questions can drive evidence-based practice, strengthen patient-physician communication, and improve safety and quality.

Role of the gender-linked norm of toughness in the decision to engage in treatment for depression

OBJECTIVE

Given their prevalence and persuasive power in our culture, gender norms--commonly described as socially reinforced, learned expectations of what it means to be a man or a woman--likely contribute to sex differences in service utilization for depression. This study investigated whether sex differences in toughness, a gender-linked norm characterized by a desire to hide pain and maintain independence, were associated with a preference to wait for depression to resolve on its own without active professional treatment ("wait-and-see" approach).

METHODS

Participants (N=1,051) in the California Behavioral Risk Factor Surveillance System (BRFSS) survey were contacted in a follow-on survey to assess toughness, the kind of treatment they would prefer were they to receive a diagnosis of depression, and current symptoms of depression. Participants who reported ever having been diagnosed as having a depressive disorder on the BRFSS were oversampled threefold. Analyses were conducted using linear and logistic regressions.

RESULTS

Men and women who scored higher on toughness had a greater preference for the wait-and-see approach (OR=1.14, p<.01). Women were less likely to prefer the wait-and-see approach (OR=.58, p<.04) and scored lower on toughness (B=-.70, p<.01). Men's greater levels of toughness partially mediated the sex difference in treatment preferences (OR=.91, p<.03).

CONCLUSIONS

Men's greater adherence to the toughness norm explained part of the sex difference observed in treatment-seeking preferences, but toughness undermined women's treatment seeking as well. Findings could be used to inform novel public health communications intended to attract both men and women to psychiatric services.

Psychotropic medication discussions in older adults' primary care office visits: So much to do, so little time

OBJECTIVES

To examine discussions of psychotropic medications during the older patient's visit to primary care physicians, identify how physician's competing demands influence these discussions, describe different scenarios physicians utilize to address mental health complaints of older adults, and recommend best practices for diagnosing and treating such patients.

METHOD

Convenience sample of 59 videotapes of primary care office visits involving mental health discussions in the United States complemented by patient and physician surveys. Videotaped visits were examined using logistic regression for grouped-level data to explore contributions of physician's competing demands to the likelihood of having psychotropic medication discussions. Tape transcripts were selected to provide examples of prescribing and referral behaviors.

RESULTS

One-third of these visits contained no psychotropic medication discussions despite its important role in treating mental illnesses. When prescribing psychotropic medicines, physicians presented information about the medication's purpose and brand name more often than adverse effects or usage. More competing demands (i.e., more topics discussed or more leading causes of disability addressed during the visit) were associated with less psychotropic medication discussions. Selected case scenarios illustrate the importance of acknowledging mental illness, prescribing psychotropic medications, explaining the medications, and/or referring patients to mental health providers to address their mental health complaints.

CONCLUSION

Competing demands may constrain discussions of psychotropic medications. Given the seriousness of mental illness in late life, system-level changes may be needed to correctly diagnose mental illness, take more proactive actions to improve mental health, and enhance information exchange concerning psychotropic medication in a manner that meets patients' needs.

Relational barriers to depression help-seeking in primary care

OBJECTIVE

To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States.

METHODS

Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25-64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes.

RESULTS

Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient-physician trust. While many reflected positively on their primary care experiences, some doubted PCPs' knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust.

CONCLUSION

Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs' mental health-related capabilities and interests.

PRACTICE IMPLICATIONS

PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions.

Adaptive choice-based conjoint analysis: a new patient-centered approach to the assessment of health service preferences

Conjoint analysis (CA) has emerged as an important approach to the assessment of health service preferences. This article examines Adaptive Choice-Based Conjoint Analysis (ACBC) and reviews available evidence comparing ACBC with conventional approaches to CA. ACBC surveys more closely approximate the decision-making processes that influence real-world choices. Informants begin ACBC surveys by completing a build-your-own (BYO) task identifying the level of each attribute that they prefer. The ACBC software composes a series of attribute combinations clustering around each participant's BYO choices. During the Screener section, informants decide whether each of these concepts is a possibility or not. Probe questions determine whether attribute levels consistently included in or excluded from each informant's Screener section choices reflect 'Unacceptable' or 'Must Have' simplifying heuristics. Finally, concepts identified as possibilities during the Screener section are carried forward to a Choice Tournament. The winning concept in each Choice Tournament set advances to the next choice set until a winner is determined.A review of randomized trials and cross-over studies suggests that, although ACBC surveys require more time than conventional approaches to CA, informants find ACBC surveys more engaging. In most studies, ACBC surveys yield lower standard errors, improved prediction of hold-out task choices, and better estimates of real-world product decisions than conventional choice-based CA surveys.

"I didn't know what was wrong:" how people with undiagnosed depression recognize, name and explain their distress

BACKGROUND

Diagnostic and treatment delay in depression are due to physician and patient factors. Patients vary in awareness of their depressive symptoms and ability to bring depression-related concerns to medical attention.

OBJECTIVE

To inform interventions to improve recognition and management of depression in primary care by understanding patients' inner experiences prior to and during the process of seeking treatment.

DESIGN

Focus groups, analyzed qualitatively.

PARTICIPANTS

One hundred and sixteen adults (79% response) with personal or vicarious history of depression in Rochester NY, Austin TX and Sacramento CA. Neighborhood recruitment strategies achieved sociodemographic diversity.

APPROACH

Open-ended questions developed by a multidisciplinary team and refined in three pilot focus groups explored participants' "lived experiences" of depression, depression-related beliefs, influences of significant others, and facilitators and barriers to care-seeking. Then, 12 focus groups stratified by gender and income were conducted, audio-recorded, and analyzed qualitatively using coding/editing methods.

MAIN RESULTS

Participants described three stages leading to engaging in care for depression - "knowing" (recognizing that something was wrong), "naming" (finding words to describe their distress) and "explaining" (seeking meaningful attributions). "Knowing" is influenced by patient personality and social attitudes. "Naming" is affected by incongruity between the personal experience of depression and its narrow clinical conceptualizations, colloquial use of the word depression, and stigma. "Explaining" is influenced by the media, socialization processes and social relations. Physical/medical explanations can appear to facilitate care-seeking, but may also have detrimental consequences. Other explanations (characterological, situational) are common, and can serve to either enhance or reduce blame of oneself or others.

CONCLUSIONS

To improve recognition of depression, primary care physicians should be alert to patients' ill-defined distress and heterogeneous symptoms, help patients name their distress, and promote explanations that comport with patients' lived experience, reduce blame and stigma, and facilitate care-seeking.